=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760868756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARIVANSH THAKAR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2015
-----------------------------------------------------
Last Update Date | 08/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 TURNER MCCALL BLVD SE
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30161-5278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-232-5270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 DULUTH HIGHWAY APT 2103
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-8809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-294-7868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 028648
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------